Evaluation and Management

of Acute Cervical Spine

Trauma

Dr.Rickky Kurniawan
General Surgery Resident
Kariadi Hospital/ Diponegoro University
Semarang-Indonesia
Introduction
The evaluation and management of cervical spine
injuries is a core component of the practice of
emergency medicine
The incidence of serious cervical spine injuries is low
but associated rates of death and disability are high
The emergency physician must have a strong knowledge
base to identify these injuries as well as clinical skills
that will protect the patient’s spine during assessment
Introduction
Cervical spine injury causes an estimated 6000 deaths and
5000 new cases of quadriplegia in the United States each
year
Males are affected 4 times as frequently as females

Two to three percent of blunt trauma patients who undergo

cervical spine imaging are diagnosed with a fracture
The second vertebra is most commonly injured, accounting
for 24% of fractures
The sixth and seventh vertebrae together account for
another 39% of fractures
Introduction
Older age is an important risk factor for cervical spine
injury: patients 65 years or older have a relative risk
twice that of younger trauma victims
The associated mortality rate in this age group is 24%.

A disproportionate number of cervical spine injuries are

associated with moderate and severe head injuries
sustained in motor vehicle crashes
Introduction
Head-injured patients are almost 4 times as likely to
have a cervical spine injury as those without head
injuries
Those at highest risk have an initial Glasgow Coma Scale
(GCS) score of 8 or lower and are likely to sustain
unstable injuries in the high cervical spine
Anatomy of Cervical Spine
 Anatomy of Cervical Spine
The cervical spine consists of 7 cervical vertebrae, the spinal cord,
intervertebral discs beginning at the C2-C3 interspace, a complex
network of supporting ligaments, and neurovascular structures.
General vertebral anatomy consists of an annular body and the
vertebral arch, including the symmetric pedicles, laminae, superior
and inferior articular surfaces, transverse processes, and a single
posterior spinous process
The cervical vertebrae are smaller than their thoracic or lumbar
counterparts, and each transverse process contains a foramen
(foramen transversarium)
The first 2 and the seventh bones have exceptional anatomic
features
C1 ATLAS & C2 AXIS
C1 ATLAS & C2 AXIS
C7 Prominens
Anatomy of Cervical Spine-C1
The first cervical vertebra is called the atlas because it
supports the head
Distinct from all other vertebrae, the atlas has no body
and no spinous process
it is a ring-like structure with anterior and posterior
arches separated by lateral masses on each side
The superior surfaces of the lateral masses articulate
with the occipital condyles of the skull, forming the
atlanto-occipital joint. Functionally, this joint allows
50% of neck flexion and extension
 Anatomy of Cervical Spine-C2
The second cervical vertebra, the axis, forms the surface on
which the atlas pivots to allow lateral rotation of the head
The dens, also called the odontoid process, is the cranial
extension of the body of the axis into the ring of the atlas; it is
the most characteristic feature of C2
The dens articulates with the posterior aspect of the anterior
ring of C1 and is stabilized by the transverse ligament. This
articulation provides stability as the atlas pivots during
rotation.
Half of neck rotation occurs at this atlantoaxial joint.

There is no intervertebral disc at either the atlanto-occipital or

the C1-C2 joints, predisposing them to inflammatory arthritis
Anatomy of Cervical Spine-C7
The distinctive feature of the seventh vertebra is its
prominent spinous process. Its length extends beyond
the other cervical vertebrae, rendering it palpable on
physical examination.
The seventh vertebra is the highest spinous process that
is reliably identifiable,making it a useful landmark.
The length and prominence of the spinous process
predispose this vertebra to fracture.
Anatomy of Cervical Spine
Intervertebral discs are interposed between the
vertebral bodies from C2 down to the sacrum; they
account for about 25% of the height of the spinal column
Structurally, discs are composed of a soft gelatinous
center, the nucleus pulposus, surrounded (the annulus
fibrosus). Functionally, discs provide support, elasticity,
and cushioning to the spine.
Intervertebral discs deteriorate with age; much of the
gelatinous center is replaced with fibrous tissue,
resulting in decreased elasticity and mobility
Ligament of Cervical Spine
The cervical spine is connected and supported by a complex network of ligaments.

Three of the most important are the anterior longitudinal ligament and the
posterior longitudinal ligament, which extend from the occiput to the sacrum, and
the ligamentum flavum.
The anterior longitudinal ligament, connecting the anterior aspects of the vertebral
bodies, becomes taut and resists hyperextension.
The posterior, connecting the posterior aspect of the vertebral bodies, tightens and
limits hyperflexion. The posterior longitudinal ligament forms the anterior surface
of the spinal canal.
The ligamentum flavum connects the laminae of adjacent vertebrae and forms the
posterior surface of the spinal canal. This ligament is susceptible to thickening with
age and may cause spinal stenosis, resulting in cord and nerve root compression.
The interspinous ligaments are thin and membranous, and span the length of the
spinous processes.
Ligament of Cervical Spine
Blood Supply of Cervical Spine
The blood supply to the spinal column and cord is
complex.
The main spinal arteries consist of a single anterior and 2
posterior vessels originating from the vertebral arteries;
they run longitudinally from the medulla along the length
of the cord.
These arteries supply only the superior portion of the
cord and are supplemented by segmental medullary
arteries originating from the vertebral arteries in the
cervical spine; they enter the spinal column through the
intervertebral foramen
Alone vessel the anterior cervical artery, is particularly
vulnerable to damage associated with hyperextension
injuries.
The result is ischemia to the anterior two-thirds of the
cord, a devastating complication
Blood Supply of Cervical Spine
The widest portion of the spinal canal is from C1 to C3,
where the mid-sagittal diameter ranges from 16 to
30mm.This diameter narrows fromC4 to C7 to a range of
from 14 to 23 mm.
At this level, the spinal cord normally occupies 40% of
the diameter of the canal in a healthy adult.
Hyperextension decreases the canal diameter
approximately 2 to 3 mm, which becomes clinically
important in the context of hyperextension injury
The cervical spine is vulnerable to trauma; injury occurs
when forces applied to the head or neck overwhelms
the anatomic stabilizers of the bony and ligamentous
support structures.
Degenerative changes resulting in spinal stenosis
increase vulnerability to cord damage, particularly with
hyperextension mechanisms.
Fatal injuries are most common at the craniocervical
junction or atlantoaxial level
PATHOPHYSIOLOGY
Axial Compression Injury

Multiple or Complex Mechanism

Flexion Mechanism

Extension Mechanism

Vertebral Artery Injury

SPINAL CORD INJURY WITHOUT RADIOGRAPHIC

ABNORMALITY
SPINAL AND NEUROGENIC SHOCK
Axial Compression Injury
The Jefferson fracture is an unstable burst fracture of the atlas
caused by severe axialcompression (Fig. 4).
Diving is a common mechanism

The injury is characterized by unilateral or bilateral fractures of

the anterior and posterior arches of C1
As an isolated injury, the Jefferson fracture is not usually
associated with neurologic injury because of the width of the
spinal canal at that level
However, when it is associated with rupture of the transverse
ligament that stabilizes the odontoid to the anterior arch of C1,
the Jefferson fracture is very unstable
Associated injuries may include damage to the vertebral
artery traversing the foramen transversarium and a
second fracture at a lower level.
A Jefferson fracture may be diagnosed on an open-
mouthed odontoid view by noting displacement of the
lateral masses of C1 relative to C2.
Overhang of C1 of 6.9 mm over the lateral mass of C2 is
diagnostic of a fracture
If this finding is not present but clinical suspicion remains,
a computed tomography (CT) scan should be obtained.
The Jefferson fracture
 Multiple or Complex Mechanism
Odontoid fractures may be 1 of 3 types. The mechanisms are mixed and
often unclear.
Flexion, extension, and rotation may contribute to the fractures.

When evaluating odontoid trauma, emergency physicians should consider

that the dens occupies one-third of the spinal canal, the spinal cord
occupies another third, and the remaining third is empty space.
A Type I fracture is an avulsion of the tip of the dens above the transverse
ligament, thought to be an avulsion fracture from the alar ligaments
In isolation, this injury is usually not associated with instability or spinal
cord injury; however, Type I odontoid fractures may be seen in
association with atlanto-occipital dislocation
This extremely dangerous injury must be ruled out before conservative
treatment is initiated
Odontoid fractures
A Type II odontoid fracture, the most common of the 3, is localized
to the base of the dens (Fig. 5).
Ten percent of these fractures are associated with damage to the
transverse ligament.
This complication represents a very unstable injury associated with
high mortality
Because of limited blood supply to the fractured dens, nonunion is
high
Patients may be treated with halo immobilization or open surgery

Risk factors for nonunion are age older than 50 years and
displacement of the fracture
Odontoid fractures
A Type III fracture extends into the body of C2 (Fig. 6).

It is a mechanically unstable injury because it allows the

atlas and occiput to move as a unit.
Nonunion is uncommon. Most patients are successfully
managed with halo immobilization.
Anderson & D’alonzo
Odontoid fractures
Odontoid fractures
Flexion Mechanism
Among flexion injuries of the cervical spine, the 2 most unstable
are the flexion teardrop fracture and the bilateral facet
dislocation
The flexion teardrop (Fig. 7) is a devastating injury in which
substantial force is required to fracture the anterior inferior
aspect of the vertebral body
Common mechanisms are motor vehicle crashes and diving

For the teardrop fracture to occur, there must be disruption of

the ligaments of the posterior column displacing the vertebral
body posteriorly into the spinal canal.
Neurologic injury is very common
Flexion Mechanism
The result is often the anterior cord syndrome, manifesting as
quadriplegia and loss of pain and temperature sensation.
The most common level for a teardrop fracture is C5

Bilateral facet dislocation is the most severe form of anterior

subluxation (Fig. 8).
At the subluxed level, the inferior facets dislocate superiorly and
anteriorly to the superior articulating facets of the lower
vertebra causing complete anterior and posterior longitudinal
ligamentous disruption.
Subluxation of more than 50% will be seen on a lateral
radiograph. Neurologic injury is common
Flexion Mechanism
Less devastating flexion injuries of the cervical spine
include wedge fractures, anterior subluxations, and clay
shoveler fractures (an avulsion fracture of the spinous
process of C7) (Fig. 9).
These injuries are usually stable, without neurologic
deficit.
An anterior subluxation must be evaluated very
carefully to rule out disruption of posterior ligaments.
Flexion teardrop fracture
Bilateral facet dislocation
Extension Mechanism
Hangman’s fracture is a fracture of the pedicles of the
axis or second cervical vertebra
The usual mechanism of injury is extreme
hyperextension during a diving accident or motor
vehicle collision
This fracture is considered unstable because of its
location, but spinal cord injury is not common because
the spinal canal is widest at C2.
The pedicle fracture allows decompression of the canal,
preventing pressure on the spinal cord
The extension teardrop fracture is a potentially unstable injury caused by
neck extension
The most common location is C2

This fracture is radiographically similar to the flexion teardrop fracture;

however, the pathophysiology and mechanism of injury are different
In forced hyperextension, tension on the anterior longitudinal ligament
causes avulsion of the anterior inferior aspect of the vertebral body
Neurologic injury is usually not severe, but it is extremely important to
prevent neck extension and thus avoid injury to the anterior ligament
When the extensor teardrop occurs at lower levels, typically C5 to C7,
central cord syndrome may be caused by buckling of the ligamentum
flavum into the cord
Hangman’s fractures
Hangman’s fractures
Extension teardrop fracture
Clay Shoveler Fracture
Vertebral Artery Injury
Vertebral artery occlusion complicates 17% of cervical spine fractures.17 The
cause of occlusion is usually vasospasm or dissection
Most unilateral injuries are not symptomatic because collateral blood is
supplied through the Circle of Willis
When present, typical clinical findings are vertigo, unilateral facial
paresthesia, cerebellar signs, lateral medullary signs, and visual field defects
The clinical significance of dissection is the predisposition to thrombus
formation, leading to basilar stroke
Cervical spine injuries at high risk for vertebral artery injury are fractures
associated with subluxation, transverse process fractures extending into the
foramen transversarium, and fractures of C1 to C3
Patients with these injuries should be screened for vertebralartery injury
The gold standard test has been 4-vessel
cerebrovascular angiography
The increasing availability of multislice CT scans has
improved the accuracy of CT angiography for
identification of vertebral artery injury
SPINAL CORD INJURY WITHOUT
RADIOGRAPHIC ABNORMALITY (SCIWORA)
Most often a spinal cord injury is associated with radiographic
findings such as fractures, ligamentous injuries, or subluxations
However, a spinal cord injury can occur when bony
abnormalities are not present
Spinal cord injury without radiographic abnormality (SCIWORA)
is defined as the presence of a spinal cord injury on magnetic
resonance imaging (MRI) in the absence of a fracture or
subluxation on CT or plain radiography
Most studies limit SCIWORA to injuries of the spinal cord, not
just a neurologic deficit that can also represent a peripheral
nerve injury or a brachial plexus injury
Once thought to be a finding primarily in children,
SCIWORA has now been found to occur more often in
adults
A retrospective review of the NEXUS data found that
3.3% of adult patients had SCIWORA,
similar to the 4.2% prevalence documented in another
more recent retrospective study
SPINAL AND NEUROGENIC SHOCK
Spinal shock is the phenomenon of loss of reflexes and
sensorimotor function below the level of a spinal cord injury
It manifests as flaccid paralysis, including the loss of bowel
and bladder reflexes and tone
Spinal shock is a temporary physiologic response to trauma
that lasts from hours to days
The degree of recovery depends on the extent of the initial
insult
Even with severe injury, patients will recover spinal cord
reflex arcs such as the bulbocavernosus and anal wink
Neurogenic shock refers to hemodynamic instability that occurs in high
spinal cord injury, including cervical cord and T1-T4
The 3 major manifestations are hypotension, bradycardia, and hypothermia

Hypotension is the result of sympathetic denervation that causes loss of

arteriolar tone and results in venous pooling
Bradycardia occurs with interruption of cardiac sympathetics, allowing
unopposed vagal stimulation
A neurogenic source of shock is suggested by the combination of
hypotension and bradycardia or variable heart rate response
Loss of autonomic regulation occurs in high spinal injuries, contributing to
hemodynamic instability and altered thermoregulation, typically
manifesting as hypothermia
PREHOSPITAL MANAGEMENT
Emergency medical services systems (EMS) have one basic principle:
deliver fast and efficient patient care for prompt transfer to a hospital
When managing cervical spine injuries, on-scene EMS personnel must
rapidly triage patients and attend to the most critical injuries
When performing the initial evaluation, the ABCDEs (airway,
breathing,circulation, disability, and exposure) should be monitored first
The airway must be secured before proceeding with the initial evaluation

If the airway needs immediate attention, manual in-line stabilization

should be maintained at all times
The first responder must always assume that an injured patient has a
spinal cold injury until proven otherwise
The initial insult causes the most damage to the cervical
spine, and caution must be taken to prevent further injury
Good immobilization techniques prevent secondary injury
and prevent the initial insult from progressing
EMS personnel follow protocols when approaching a patient
with a potential cervical spine injury
The first step is to survey the scene and ensure that it is safe
to approach the patient
After securing the ABCs, the EMS provider can move on to
the secondary survey, assessing the extent of injuries
For any trauma patient, EMS providers follow standard
immobilization procedures
The physician who receives the patient in an emergency
department will see various types of immobilization
The most common are the backboard, the rigid cervical collar,
spider straps, and head blocks.
The most important point is to secure the patient to the
backboard to minimize movement in case the patient vomits and
needs to be rolled onto the side to prevent aspiration
Another immobilization device is the Kendrick Extrication Device
(KED)
The protocol for spinal
immobilization is as follows:
1. Maintain the head in neutral in-line position with a
cervical collar in place
2. Logroll the patient onto the backboard

3. Secure the torso with spider straps or buckle straps

4. Secure the head to the backboard with foam blocks

or towel rolls
5. Secure the legs to the backboard
The backboard has claimed itself as the gold standard for spine
immobilization in the prehospital setting
The backboard helps maintain neutral position of the spinal column
en route and helps facilitate easy transfer once at the hospital
Occipital padding achieves the most neutral position; without it 98%
of the patients would be in relative extension
Studies are unclear regarding how long the patient should remain on
the backboard before he or she is at risk for developing
complications, such as increased discomfort or pressure ulcers
Current recommendations suggest timely removal from the backboard
as soon as the primary survey is complete and the patient is stable, to
avoid such complications
EMERGENCY DEPARTMENT
EVALUATION
Clinical Assessment
A missed cervical spine injury can have devastating
consequences
When approaching the trauma patient to evaluate the
cervical spine, the emergency physician should first consider
whether the spine can be cleared without the use of imaging
It is best to approach the cervical spine evaluation in a
structured manner
An unstructured approach to examining the cervical spine
has low sensitivity compared with a more systematic
approach
One can apply structured clinical decision rules in alert stable
patients without neurologic deficits to determine how to proceed
with the workup to evaluate for a clinically significant cervical
spine injury
A clinically important cervical spine injury is defined as any
fracture, dislocation, or ligamentous instability demonstrated on
diagnostic imaging
A clinically unimportant injury is defined as an isolated avulsion
fracture of an osteophyte, an isolated fracture of a transverse
process not involving a facet joint, an isolated fracture of a
spinous process not involving the lamina, or a simple compression
fracture involving less than 25% of the vertebral body height
Airway Management
Patients presenting to the emergency department may require emergency airway
management before a full assessment for cervical spine injuries can be performed
When approaching the trauma patient, the physician should assume that an injury
to the cervical spine is present
If the patient has an associated head injury, witha GCS score of less than 9, the
risk of cervical spine injury increases significantl
 This patient is also the one who most likely needs an emergent airway

Lesions above C3 cause immediate need for airway management because of

respiratory paralysis
Lower lesions may cause phrenic nerve paralysis or increasing respiratory distress
from ascending edema. Injuries to the cervical spine may cause local swelling,
edema, or hematoma formation that may obstruct the airway, necessitating
intubation
Recommendations for managing
the airway of a trauma patient
are
1. Rapid-sequence intubation (RSI): When managing an unconscious
patient, standard drugs should be used for paralysis and induction

2. Manual in-line stabilization: An assistant firmly holds both sides of the

patient’s head, with the neck in the midline and the head on a firm
surface throughout the procedure, to reduce cervical spine movement
and minimize potential injury to the spinal cord

3. Orotracheal intubation is preferred in trauma patients requiring

intubation

4. Use a tracheal tube introducer such as a Bougie or stylet

5. Have a selection of blades ready: evidence supports the use of a

Macintosh blade

6. A laryngeal mask airway (LMA) can be used as a temporary device.

Manual in-line immobilization (MILI), as described by Crosby,33 is designed
to hold sufficient forces on either side of the head to prevent movement
during interventions such as airway management
There are 2 approaches to MILI: (1) an assistant standing at the head of the
bed grasps the patient’s mastoid process with the fingertips and then
cradles the occiput in the palms of the hands; or (2) an assistant standing at
the side of the bed cradles the mastoids and grasps the occiput with the
fingers
Once the head and neck are stabilized by one of these methods, the front
of the cervical collar can be removed to increase mouth opening and
visualization by direct laryngoscopy
The neck should be maintained in neutral position throughout the
procedure, and the anterior aspect of the collar should be replaced
promptly when it has been completed.
Cord-Level Findings
Neurologic deficits correlate with the level of the injury, resulting in
weakness or paralysis below the lesion
There are 8 pairs of spinal nerves in the cervical spine. The dermatomal
distribution for the cord at each vertebra is listed in Fig. 12
From C1 to C7, the nerve root exits above the level of the vertebra;
from C8 and below, the nerve root exits below the level of the
vertebra.
The presentation of incomplete cord injuries depends on the level and
location of the lesion
The anterior column conveys motor function, pain, and temperature,
and the posterior column conveys impulses related to fine touch,
vibration, and proprioception
Asia score
Evaluasi Asia Score
Partial Cord Syndromes
Anterior cord syndrome results from compression of the
anterior spinal artery, direct compression of the
anterior cord, or compression induced by fragments
from burst fractures
Anterior cord syndrome manifests as complete motor
paralysis, with loss of pain and temperature perception
distal to the lesion
Posterior cord syndrome is very rare; involvement of the
posterior column is most often seen in Brown-Se´ quard
syndrome
Brown-Sequard syndrome
Brown-Sequard syndrome is characterized by paralysis,
loss of vibration sensation, and proprioception
ipsilaterally, with contralateral loss of pain and
temperature sensation
These signs and symptoms result from hemisection of
the spinal cord, most often from penetrating trauma or
compression from a lateral fracture
Central cord syndrome
Central cord syndrome, induced by damage to the
corticospinal tract, is characterized by weakness in the
upper extremities, more so than in the lower
extremities
The weakness is more pronounced in the distal portion
of the extremities
This injury is usually caused by hyperextension in a
person with an underlying condition such as stenosis or
spondylosis
CERVICAL SPINE IMAGING
Two decision rules guide the use of cervical spine radiography in patients
with trauma: the NEXUS Low Risk Criteria (NLC) and the Canadian C-Spine
Rule (CCR)
The NLC were derived from the National Emergency X-radiography Use
Study (NEXUS), which was designed to identify patients who do not need
diagnostic imaging to exclude a clinically significant cervical spine injury.
Cervical spine radiographs are indicated for trauma patients unless they
have all of the following 5 characteric
they are alert, are not intoxicated, have no posterior midline tenderness,
have no neurologic indications of the injury, and have no distracting
injuries (eg, a long bone fracture, a large laceration, a crush injury, a
large burn, or another injury that produces acute functional impairment).
The definitions of “intoxicated” and “distracting injury”
are open to interpretation, requiring physician
judgment in deciding whether to obtain imaging studies
The CCR was developed out of concern for the
potentially low specificity and sensitivity of the NLC for
detecting clinically significant cervical spine injuries
The CCR poses 3 questions

1. Does the patient have any high-risk factors? Patients are at higher risk if
they are older than 65 years, if their mechanism of injury was “dangerous,”
or if they experienced paresthesia in the extremities after the injury.
Examples of dangerous mechanisms of injury include fall from a height
greater than 3 ft, axial load to the head, high-speed motor vehicle crash,
rollover, ejection, and bicycle crash.

2. Are any low-risk factors present that would allow a safe assessment of
range of motion? Low-risk criteria include simple rear-end motor vehicle
crash, the ability to sit upright in the emergency department, ambulation
at any point after the incident, delayed onset of neck pain, and the
absence of midline cervical spine tenderness.

3. Is the patient able to actively rotate the neck 45 to the left and right? If
the patient has active rotation of the neck as well as low-risk factors and
the absence of high-risk factors, then the physician can safely clear the
spine without radiographic imaging
A prospective cohort study done in Canada found the
CCR to be more sensitive (99.4% vs 90.7%) and specific
(45.1% vs 36.8%) than the NLC for detecting injury
In addition, the CCR resulted in decreased radiography
rates (55.9% vs 66.6%)
Imaging Modalities
Three methods exist for imaging the cervical spine in the emergency department:
plain radiographs, CT, and MRI
Each has advantages and disadvantages, and the clinical situation must be
considered when deciding which method to use.
Plain radiography typically includes 3 views: anteroposterior, lateral, and odontoid.

This imaging modality is falling out of favor because its false-negative rate is higher
than that associated with CT.
Emergency departments commonly rely on CT imaging to evaluate patients for injury

CT allows easy imaging of the cervical spine when clinically indicated

A CT scan is best for detecting bony abnormalities; it can detect 97% of osseous
fractures
When ligamentous injury or spinal cord injury is suspected, MRI is indicated
EMERGENCY DEPARTMENT
MANAGEMENT
The treatment of cervical spine injuries begins after the initial
clinical evaluation
After management of the airway, attention to hemodynamic support
and blood pressure management is essential
Hypotension should not be attributed to neurogenic shock until blood
loss or other trauma-related causes have been managed or ruled out
Regardless of etiology, it is critically important to aggressively
manage hypotension in patients with cervical cord injuries
Hypotension is associated with worse outcomes and is thought to
contribute to secondary injury because of reduced spinal cord
perfusion
The goal for optimal spinal cord perfusion is maintenance of a mean arterial
pressure of 85 to 90 mm Hg
Unstable patients require arterial lines and central venous or Swan Ganz
monitoring
Initial treatment is with crystalloid. If indicated, blood transfusion should be
started to correct blood loss
After volume correction, if the mean arterial pressure remains low, pressors
should be initiated
A vasopressor should be chosen with the goal of treating both hypotension and
bradycardia
Agents witha- and b-agonist properties, such as dopamine, norepinephrine, or
epinephrine, are preferred to provide both inotropic and chronotropic support
In patients with a cervical spine injury and abnormal neurologic
examination, the question of the efficacy and safety of
methylprednisolone arises.
NASCI II used a much higher dose of methylprednisolone (a 30-
mg/kg bolus followed by a 5.4-mg/kg/h infusion for 23 hours
This group was compared with patients with comparable injuries
treated with a naloxone regimen or placebo. A total of 487
patients were enrolled and divided into 3 treatment arms
Patients in the methylprednisolone arm treated within 8 hours of
injury had a statistically significant improvement in motor and
sensory function at 6 months compared with those in the other 2
groups
THANK YOU